Supporting nutritional intake in nursing homes

during the COVID-19 pandemic

Dietetic perspective : The HSE Nutrition Supports Pack for Residential Care Settings for Older Persons during COVID-19

Available at www.hse.ie/nutritionsupports

Dr Sharon Kennelly , Clinical Specialist Dietitan

HSE National Nutrition Support Programme

The Key MessageMalnutrition Risk- Treat without delay

• There is only a small window of opportunity to act swiftly and appropriately to prevent someone’s physical decline due to decreased nutritional intake exacerbated by illness and associated clinical interventions.

• Malnutrition can be life-threatening if poor nutritional intake or an inability to eat persists for several weeks (NICE, 2006)

Why is nutrition support so important ?

• In absence of COVID-19 infection– Slow frailty progression/build resilience – Optimise health and immunity– Quality of life

• During COVID -19 infection– Decrease complications and morbidity – Quality of life

• Post-COVID -19 recovery – Optimum rehabilitation – Quality of life

Covid-19 infection increases malnutrition risk due to the effects of the disease and its management (e.g. anorexia, breathlessness, impact of management options (sedation, CPAP/NIV), changes to taste and smell, psychological factors (e.g. anxiety), social restrictions etc.)

(MAG , 2020)

Why is nutrition support so important ?

• In absence of COVID-19 infection– Slow frailty progression/build resilience – Optimise health and immunity– Quality of life

• During COVID -19 infection– Decrease complications and morbidity – Quality of life

• Post-COVID -19 recovery – Optimum rehabilitation – Quality of life

Covid-19 infection increases malnutrition risk due to the effects of the disease and its management (e.g. anorexia, breathlessness, impact of management options (sedation, CPAP/NIV), changes to taste and smell, psychological factors (e.g. anxiety), social restrictions etc.)

(MAG , 2020)

Increased nutritional requirementsDecreased intake /absorption

Inflammation Immobility

Lean tissue and functional loss Poorer outcomesIncreased Frailty

Dietitians Role in the Residential Care Facility

Nutritional Assessment & Care Plan development

Nutrition Steering

Committee/Team Leaders

Nutrition hydration policy development &

Audit

Liaison with catering menu review

Specialised DietsMealtime observation

Tube feeding

How to identify residents at risk? (SCREEN)

Who to assess for further treatment? (ASSESS)

What treatment is appropriate? (TREAT)• Dietary counselling

• Special Dietary Requirements e.g. Diabetes, Renal, Gluten Free

• Modified consistency diets

• Food fortification

• Oral nutritional supplements

• Enteral tube feeding

Overview

SCREEN

Low risk Medium RiskHigh Risk

(Refer to Dietitan)

OBSERVE A= ASSESSC= CONSIDERT = TREAT

ROUTINE CARE

Identify those ‘at risk’

Screening is only screening !- but it allows you target resources and care

COVID-19 Nutrition Support Guidance –Version 1

Aim: To highlight importance of nutrition and to give emergency guidance

• Developed by Dietitians from HSE residential care facilities with input from SALT colleagues

• HSE Clinical Advisory Group approval

• Feedback from NCPOP, DONs, GPs, Pharmacy

• Liaison with nutrition industry, professional bodies

• Does not replace agreed local policies pathways or services or AHP input

• 2 week turnaround

Nutrition Screening during COVID -19If you have a pathway and are able to maintain this don’t change it !

• MUST • (Malnutrition Universal Screening Tool )

• It includes a BMI score, a weight loss score, and an acute disease score

• Use reported, alternative and /or subjective measures if physical measurements are restricted

• due to ICP

• Apply Acute Disease effect Score if no or little nutritional intake for last 5 days or expected for next 5 days

(MAG, 2020)

• MNA-SF • Mini-Nutritional Assessment Short Form

• Six parts to assess food intake loss, weight loss, mobility, physical stress or acute illness, cognitive status, and BMI

• Older person specific tool• Some evidence that it may be

a more sensitive tool than MUST in context of COVID-19 in acute setting

(Liu et al, 2020)

Nutrition Screening during COVID -19

• 40- 85%* patients over 65 years with COVID-19 were at risk of malnutrition (*variance depending on tool used)

• Patients at risk of malnutrition had significantly longer LOS, higher hospital expenses, poorer appetite, and heavier disease severity than those not at risk

• Authors recommend early intervention for patients with COVID-19 who are found to be at nutritional risk to prevent further decline in nutritional status and improve clinical outcomes

In absence of formalscreening – i.e. ‘war-times’

Be vigilant for residents who have:• Sudden changes in appetite and food intake

– Are eating less than half of meals when previously would have eaten most or all of meals

– Importance of feedback from staff who provide assistance with eating

• Unplanned weight loss • Increase frequency of weight monitoring if possible, importance of staff

observation e.g. when assisting e.g. loose clothes, belt notch.

• Onset of new GI symptoms or dysphagia• Abdo-pain, loss of appetite, nausea, vomiting, diarrhoea, swallowing

difficulties, loss of smell or taste

• Intolerance of enteral feed (If tube fed)

Protected Mealtime : Real challenges Importance of dining experience

and assistance with feeding

Additional pressures during COVID -19 due to ICP measures , reduced staff, increased numbers of residents requiring assistance, no dining room experience , no visitors or days out .

What can we do to limit the impact of local Infection Control and Prevention guidelines?• Food intakes monitored and documented in the relevant notes, e.g. food chart• Make mealtime setting calm and free from any unnecessary distractions • Ensure food at the appropriate temperature? Fridge in room ?• Importance of access regular fluids and high protein high calorie snacks• Soft foods -sore throat – Extra sugar / Butter /Flavourings? -altered or taste

and smell . Presentation is still very important.• Fresh air before a meal . Company with a favourite staff member.

Key Actions Making the Most of Every Bite

High Protein High Calorie Menu

• Three energy and protein dense meals per day

• Local system to ensure that ‘at risk’ residents receive this

• Food fortification : Adding additional butter, cream , cheese, skimmed milk powder to meals

• 3 snacks per day • Snack and fluids supply in room if

possible / individually packaged foods /own fridge

• Recipes and Dementia resource at www.hse.ie/nutritionsupports

(Energy and Protein Requirements available at ESPEN,2020)

Key ActionsMake the Most of Every Sip

• Include fluids that also have calories and protein in Drinks Menu instead of fluids with low/no nutritional value tea, coffee, Bovril, packet soups

• Consider introducing High protein milkshakes or soup in am & pm between meals

• Foods with high fluid content Ice-pops, ice-cream , custard• Recipes available in ‘Making most of every bite cookbook’ at

www.hse.ie/nutritionsupports

Oral Nutritional Supplements

Evidence suggests protein & energy requirements can be significantly increased with use of ONS

As per guidance in pack – 2 x High Protein ONS per day (> 20% energy from protein) – Consider volume patient is likely to take , taste preferences .– Safe swallowing recommendations (See guidance and SALT) . – Can be combined with foods e.g. neutral or vanilla flavours added

to porridge ,as a custard over puddings etc. – Can be divided into shots of smaller volumes over day e.g. 4 x 60-100ml shots instead of 125mls or 200ml.b.d – In our experience after breakfast and late pm good times . – Consult dietitian if using as a short term sole source of nutrition

• (1-2 ONS will not meet nutritional needs, MANY types are not suitable )

Monitoring

When the resident is established on adequate oral intake from food:

– Food records , weight stable or increasing

– Consider reducing the quantity of ONS gradually after 1 month. Continue to monitor for recurrence of risk of malnutrition

If further weight loss / reduced appetite :

– MDT discussion needs to happen as soon as

possible taking into account Advanced Care Plan

– Short –term NG feeding may be appropriate to

consider for some residents in residential care facilities

– Local MDT communication pathways for decision making needs to be in place

– (Guidance on when to initiate Enteral (Tube) Feeding during COVID-19 ESPEN ,2020)

•

Other considerations Importance of Advanced Care Planning • Include nutrition and hydration wishes in ACP conversations

and clearly document these– IV hydration, bloods, use of ONS, NG feeding, longer term tube

feeding.

• Good communication between the MDT team and with the patient and family is essential

End of life considerations• Advise patient and family that, at this time, care should focus

on enjoyment of food rather than quantity of food consumed or reversing weight loss.

• Provide assistance and support at mealtimes as required.• Offer favourite foods.• Encourage the resident to eat little and often as tolerated. • Additional resources at www.hse.ie/nutritionsupports

Residents with long term enteral feeding tubes

• Residents who use enteral nutrition (tube feeding) and are experiencing weight loss or difficulties tolerating their usual enteral feeding regimen should be referred to a dietitianimmediately.

• Any new resident who has recently transferred to the nursing home on enteral nutrition, should be referred to a dietitan.

• If deemed necessary to hold the feed for a prolonged length of time (>1day), reintroduce at a lower rate and increase rate every 4-6hours. Inform the dietitian so this can be monitored

Refeeding Syndrome(See also detailed guidance at www.irspen.ie)

If risk factors for re-feeding syndrome are present /suspected the following is recommended in consultation with the GP:/Senior Clinician in charge

• Where possible an initial check of blood mineral levels is advisable. – Include K+,Mg++,PO43-,Ca++, U&E’s (unless palliative /end of life)

• Reintroduce food & Oral Nutritional Supplement (ONS) gradually, building up slowly to full meals and ONS dosage over 5 days – refer to dietitian for specific guidance. Same applies to enteral feed (Consult dietitan).

• Prescribe Thiamine ≥250mg IV daily for 3 days OR 200-300mg PO for 10 days

• Prescribe general multivitamin and mineral supplement

• In acute setting: it is recommended best practice to request blood test electrolytes (U&E, Ca, PO4, Mg) daily for 5 days and then alternate days until stable. Electrolytes should be replaced where required, and ECG monitored where possible.

• In residential care facilities : What is possible ? An initial check repeated after 2-3 days - It is a challenge to to supplement safely in this setting!

• It is safe to advise 20μg (800iu) vitamin D as a daily supplement (if no contraindications) to those who are NOT already on prescribed combination calcium/vitamin D supplements.

• For more information on vitamin D requirements please see McKenna and Flynn, Irish Medical Journal (May 2020).

• Vitamin D content of commonly used supplement and ONS

Vitamin D

Need more information

• For general queries on nutrition support and to contact the office of the HSE national nutrition advisor at nutrition.national@hse.ie

• For queries on ONS reimbursement system at ONS.PCRS@hse.ie

• To contact local HSE community dietitan manager in your area. See contact details at www.hse.ie/nutritionsupports

• To contact a private registered dietitan www.indi.ie

Acknowledgements

Dietitians

• Margaret O Neill, HSE National Nutrition Advisor & Marian Mc Bride, Senior Dietitian• Anne Marie Bennett Senior Dietitian, St. Mary’s Hospital Phoenix Park Dublin and HSE

PCRS • Maria McKenna Senior Dietitan, CHO 6 & Chair of Older Persons Interest Group INDI • Marian McBride Senior Project Dietitan HSE • Niamh Maher, Senior Home Enteral Feeding Dietitan, CHO 9• Mary McKeon, Clinical Specialist Dietitian, CHO 8• Carmel O’ Hanlon Clinical Specialist Dietitan, Beaumont HospitalOthers• Speech and Language Therapy Colleagues in CHO 8 & 9• Medical colleagues, GPs Representative's, National Clinical lead for Older Persons and

Palliative Care , National Clinical Advisory Group . • Directors of Nursing, Public and Private Residential Care Facilities • Medical Nutrition Industry Abbott, Fresenius Kabi, Nualtra , Nutricia, Aymes• IRSPEN & INDI

References

• IrSPEN GUIDELINE DOCUMENT No. 1:Prevention and Treatment of Refeeding Syndrome in the Acute Care Setting Available at https://www.irspen.ie

• (ESPEN 2020) ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection, Clinical Nutrition, https://doi.org/10.1016/j.clnu.2020.03.022

• (MAG 2020) Practical guidance for using 'MUST' to identify malnutrition during the COVID-19 pandemic Malnutrition Action Group (MAG) update available at https://www.bapen.org.uk/screening-and-must/must-calculator

• (NICE 2006) Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition Clinical guideline [CG32] Published date: 22 February 2006 Last updated: 04 August 2017. Available at https://www.nice.org.uk/guidance/cg32

• Department of Health (2019). Nutrition screening and use of oral nutrition support for adults in the acute care setting. (NCEC National Clinical Guideline No.22 ). Available at: http://health.gov.ie/national-patient-safety-office/ncec/national-clinical-guidelines.

• Liu et al (2020) Clinical significance of nutritional risk screening for older adult patients with COVID-19 EJCN DOI: 10.1038/s41430-020-0659-7

• Barazzoni R et al (2020) , ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection, Clinical Nutrition, https://doi.org/10.1016/j.clnu.2020.03.022